Citation NR: 9614781
Decision Date: 05/28/96 Archive Date: 06/11/96
DOCKET NO. 94-35 943 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Detroit,
Michigan
THE ISSUE
Entitlement to service connection for post traumatic stress
disorder.
REPRESENTATION
Appellant represented by: Military Order of the Purple
Heart
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Howard M. Scott, Associate Counsel
INTRODUCTION
This matter comes before the Board of Veterans’ Appeals (BVA
or Board) on appeal from a January 1993 rating decision of
the Department of Veterans Affairs (VA) Regional Office (RO)
in Detroit Michigan, which denied the veteran's claim for
service connection for post traumatic stress disorder (PTSD).
The veteran who had active service from November 1965 to
August 1967, appealed that decision to the BVA and the case
was referred to the Board for appellate review.
REMAND
In the November 1994 Supplemental Statement of the Case the
RO writes that there is no evidence of record to corroborate
the veteran's history of stressful events. The Board notes,
however, that the veteran’s award of the Combat Infantryman
Badge is presumptive evidence that the veteran was exposed to
combat stressors while in Vietnam. 38 C.F.R. § 3.304(f)
(1995).
A preliminary review of the record reveals that the November
1992 VA psychiatric examination administered to the veteran
does not provide a diagnosis sufficient for purposes of
deciding the veteran’s appeal. Specifically, the diagnosis
contains language that appears to deny the presence of PTSD
but is somewhat equivocal in referring to the severity of the
PTSD standards. It is unclear whether this means the
criteria are not met or that they are met but merely warrant
a non-compensable evaluation. The examination report
concludes by stating that the examination has to be regarded
as incomplete. In addition, in September 1993 the veteran
was diagnosed by his own psychologist as suffering from PTSD,
who further opined that the disorder had been present for the
past twenty seven years.
In view of the foregoing, and in order to fairly and fully
adjudicate the veteran’s claim, the case is REMANDED to the
RO for the following action:
1. The RO should ask the veteran to
provide the names and addresses of all
medical care providers who treated the
veteran for PTSD since December 1992.
After securing the necessary release, the
RO should obtain copies of all treatment
and other medical records. Once obtained
these records should be included in the
veteran's file.
2. The veteran should be afforded an
examination by a board of two
psychiatrists. The purpose of the
examination is to determine the nature,
severity and etiology of any psychiatric
disorder which may be present, and to
determine whether the veteran meets the
diagnostic criteria for a diagnosis of
PTSD as set forth in the American
Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders.
Any and all indicated evaluations,
studies and tests deemed necessary by
the examiners should be accomplished,
but should include psychological
testing. Since it is important "that
each disability be viewed in relation to
its history(,)" 38 C.F.R. § 4.1 (1992),
all pertinent medical records in the
veteran's claims file or, in the
alternative, the claims file, must be
made available to the examiners for
review prior to, and during, the
examinations.
When the development requested has been completed, the case
should again be reviewed by the RO on the basis of the
additional evidence. If the benefit sought is not granted,
the veteran and his representative should be furnished a
supplemental statement of the case, and be afforded a
reasonable opportunity to respond before the record is
returned to the Board for further review.
The purpose of this REMAND is to obtain additional
development, and the Board does not intimate any opinion as
to the merits of the case, either favorable or unfavorable,
at this time. No action is required of the veteran until he
is notified.
CONSTANCE B. TOBIAS
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1995).
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